2016 AGING SERVICES PROGRAM DESCRIPTIONS

Transcription

1 2016 AGING SERVICES PROGRAM DESCRIPTIONS Contents Adult Day Services... 2 Assisted Living... 2 Person-Centered Long-Term Care Community... 3 Home and Community Services... 3 Case Management... 4 Independent Senior Living... 5 Dementia Care Specialty Program... 5 Stroke Specialty Program Aging Services Program Descriptions 1

2 Adult Day Services An adult day services program is a nonresidential program that provides supervised care to adults of all ages in a supportive and safe setting during part of a day. Assessments of the persons served and their families/support systems and person-centered plans of care drive the delivery of services. An adult day services program provides or arranges for services that include, but are not limited to, therapeutic activities, nutrition, health and personal care, and transportation. Adult day services programs typically deliver services through a social model and/or a medical model. Either of these might provide services to specialized populations of persons served. By supporting family systems, an adult day services program enables the persons served to live and engage in the community and provides the family system with an opportunity to fulfill daily responsibilities and for respite. An adult day services program strives to optimize the dignity, choice, preferences, autonomy, and quality of life of the persons served. Assisted Living Assisted living is a residential program that provides meals, housing, and a range of hospitality and personal care services for adults of all ages in a supportive and safe home-like setting. Assisted living strives to optimize the dignity, choice, preferences, autonomy, engagement in life roles, and quality of life of the persons served. The program might provide services for specialized populations of persons served. Assisted living offers a culture of customer service and hospitality as well as an environment of safety and security for persons served. A philosophy of independence, engagement, and wellness guides the communications between personnel and persons served in assisted living. Assessments of the persons served and their person-centered plans drive service delivery. Coordination of care and care delivery are conducted in accordance with applicable regulations for the assisted living program. Staffing is provided 24 hours a day, 7 days a week. A variety of services ranging from minimal to intensive assistance with activities of daily living such as bathing, dressing, eating, grooming, mobility, toileting, and assistance with medications may be available, as well as referrals to external services. Assisted living programs may provide some health services and intermittent nursing care. Additionally, these programs may offer housekeeping, laundry services, medication management, recreation programs, and transportation. Assisted living programs are provided in a variety of settings from a small home with just a few individuals to a high-rise building housing many individuals. Individual living accommodations can be private or shared and include a single room or a full-size apartment. [Canada] Note: Assisted living may have different names in different jurisdictions Aging Services Program Descriptions 2

3 Person-Centered Long-Term Care Community Person-centered long-term care communities, such as nursing homes or long-term care homes, may include freestanding homes, homes that are part of continuums of care, or homes that are part of health systems. Person-centered long-term care communities are residential programs that provide nursing and other services 24 hours a day, 7 days a week. Programs may offer long-term services, short-term services, or both to address a variety of needs. Person-centered long-term care communities foster a holistic culture that focuses on: Autonomy, dignity, and individual choice of the persons served. Relationships among persons served, families/support systems, and personnel. Understanding what services persons served want, how the services should be delivered, and how the persons served can be engaged in the community. Persons served making decisions about the rhythm of their day, the services provided to them, and the issues that are important to them. Cultural competence, flexibility, and safety and security of the community. Persons served are the experts regarding life in their home. Their voices are heard and their life stories, wishes, and needs drive service delivery. Persons served and personnel celebrate the cycles of life and connect to the local community to continue relationships that nurture the quality of everyday life. Leadership commits to continuous learning and growth, team work, empowerment, responsiveness, and spontaneity. A person-centered long-term care community is a place where persons served want to live, people want to work, and both choose to stay. Home and Community Services Home and Community Services (HCS) are person centered and foster a culture that supports autonomy, diversity, and individual choice. Individualized services are referred, funded, and/or directed by a variety of sources. In accordance with the choice of the person served, the services provided promote and optimize the activities, function, performance, productivity, participation, and/or quality of life of the person served. The Home and Community Services may serve persons of any ages, from birth through end of life. Services may be accessed in a variety of settings including, but not limited to, private homes, residential settings, schools, workplaces, community settings, and health settings. Services are provided by a variety of personnel, which may include health professionals, direct support staff, educators, drivers, coaches, and volunteers and are delivered using a variety of approaches, supports, and technology. Services are dynamic and focus, after a planning process, on the expectations and outcomes identified by both the person served and the service providers. The service providers are knowledgeable of care options and linkages to assist the person served; use resources, 2016 Aging Services Program Descriptions 3

4 including technology, effectively and efficiently; and are aware of regulatory, legislative, and financial implications that may impact service delivery for the person served. The service providers are knowledgeable of their roles in and contribution to the broader health, community, and social services systems. Home and Community Services must include at least one of the following service delivery areas: Services for persons who are in need of specialized services and assistance due to illness, injury, impairment, disability, or a specific age or developmental need. Services for persons who need assistance to access and connect with family, friends, or co-workers within their homes and communities. Services for persons who need or want help with activities in their homes or other community settings. Services for caregivers that may include support, counseling, education, respite, or hospice. Note: A service provider seeking accreditation for Home and Community Services is not required to provide all four of the service delivery areas identified in the service description. However, it must include in the site survey all of the service delivery areas it provides that meet the service description. Case Management Case Management proactively coordinates, facilitates, and advocates for seamless service delivery for persons with impairments, activity limitations, and participation restrictions based on the following: Initial and ongoing assessments. Knowledge and awareness of care options and linkages. Effective and efficient use of resources. Individualized plans based on the needs of the persons served. Predicted outcomes. Regulatory, legislative, and financial implications. The delivery of case management may occur in a variety of settings that include, but are not limited to, a healthcare environment, a private practice, in the workplace or in the payer community Aging Services Program Descriptions 4

5 Independent Senior Living Independent senior living communities are congregate community housing settings that may be stand-alone or part of continuums of services. Persons served may reside in apartments, cottages, or other settings in the independent senior living environment. Independent senior living offers a culture of customer service and hospitality as well as an environment of safety and security for persons served. A philosophy of independence, engagement, and wellness guides the communications between personnel and persons served in independent senior living. As part of the residency and service agreement, various hospitality services may be accessed by persons served, including, but not limited to, transportation, dining, housekeeping, laundry, and social and recreational activities. Dependent on the information in the written agreement between the person served and the program, persons served may pay additional fees for various services. Information on resources in the local community may also be offered to persons served. Persons served manage or make their own arrangements for management of personal care, medications, health care, and activities of daily living. Dementia Care Specialty Program A Dementia Care Specialty Program delivers services that focus on the unique and changing physical, cognitive, communication, emotional, psychosocial, behavioral, occupational, medical, palliative, educational, environmental, and leisure/recreational needs of persons with dementia. Leadership fosters a relationship-centered culture in which persons served, families/support systems, and all personnel are empowered to make decisions in partnership based on the preferences, strengths, and needs of the person served. The program integrates services to: Preserve dignity and personhood. Minimize the impact of impairments and secondary complications. Maximize participation, including wellness, quality of life, and inclusion in the community. Decrease environmental barriers. Promote personal safety and security. A Dementia Care Specialty Program recognizes the individuality, preferences, strengths, and needs of the persons served and their families/support systems. It provides access to information, services, and resources to enhance the lives of the persons served and their families/support systems, facilitate engagement in meaningful activity, promote personal health and wellness, and preserve quality of life Aging Services Program Descriptions 5

6 The program demonstrates the commitment, capabilities, and resources to maintain itself as a specialized program for persons with dementia. Current research and evidence inform the implementation of service delivery models and strategies. A Dementia Care Specialty Program engages and partners with stakeholders to increase access to services by advocating for persons with dementia to regulators, legislators, educational institutions, research funding organizations, payers, and the community at large. A person-centered philosophy is embraced and modeled by all personnel. Caring and respectful relationships make persons served, personnel, and other stakeholders feel valued. Stroke Specialty Program A stroke specialty program, through application of the research available to clinical practice, delivers services that focus on the unique needs of persons who have sustained a stroke, including: Minimizing impairments and secondary complications. Reducing activity limitations. Maximizing participation and quality of life. Decreasing environmental barriers. Preventing recurrent stroke. The program recognizes the individuality, preferences, strengths, and needs of the persons served and their families/support systems. A stroke specialty program assists the persons served and their families/support systems to manage their own health, encourages their appropriate use of healthcare systems and services, and supports their efforts to promote personal health and wellness and improve quality of life throughout their life span. The program provides ongoing access to information, services, and resources available to enhance the lives of the persons served within their families/support systems, communities, and life roles. A stroke specialty program partners with the persons served, families/support systems, and providers within and outside of rehabilitation throughout phases of care from emergency through community-based services. A stroke specialty program fosters an integrated system of care that optimizes prevention, recovery, adaptation, and participation. A stroke specialty program contributes to the development of stroke systems of care by partnering with providers within and outside of rehabilitation to increase access to services by advocating for persons who have sustained a stroke to regulators, legislators, educational institutions, research funding organizations, payers, and the community at large. A stroke specialty program utilizes current research and evidence to provide effective rehabilitation and supports future improvements in care by advocating for or participating in stroke research Aging Services Program Descriptions 6